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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all CU N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, <br /> CD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v CL <br /> lations of the State of Wisconsin. <br /> ° O <br /> . . .�. . <br /> Owner or Agent (please print) Contractor or SurveyorCD <br /> HCD <br /> c <br /> CL <br /> Address Address <br /> CD <br /> Phone Phone <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber Well Driller <br /> 0 <br /> Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . G) <br /> n ° <br /> 0 <br /> Phone Phone <br /> 0 O <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Type of Construction No. Bathrooms • • • • • • o Z <br /> 1. Work . . . . . . . No. Bedrooms <br /> o m <br /> New Building . . . . . . Size . . . ;t. x . ,,�.,1! ft. Septic Tank Size Gals. . . . . . . <br /> Addition : . . Height . .7//6 ories . . . . . . W <br /> < r- <br /> Sanitary . . . . . . Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: <br /> Filling . . . Soil Type . . . . . . . . . . . . . . . . . . o <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home Sanitary / Dry Well CD CD <br /> Privy . . . . . . Building �/ Seepage Trench fD `D <br /> Well . . . . . . Well Privy . . . . . . fn <br /> Subdivision Other (Specify) Seepage <br /> Bed in <br /> Conditional . . . . . . N N <br /> 2. Classification Land Use . . . . . . h <br /> Zoning Dist. . . . . . . °, o <br /> 6. Use (describe exactly, 1 -fam. H' <br /> 3. Lot Size home, motel et .) FOR COMMERCIAL USE ° <br /> �l. . . . ft. x +r '. ft. 3G6 �� Plans Submitted <br /> ° <br /> . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. � Plans Approved . . . . . . =--- <br /> -------------------- <br /> ---- ---- --------------- ------------ <br /> Fig. <br /> A. proposed Location of structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched _ <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location -o <br /> and setback from all bodies of water. ' <br /> < If property is located at a highway in :n <br /> tersection, show the intersecting high- <br /> /0 ways and the setbacks required along `^ <br /> them and at the intersection. <br /> PERMIT FEES <br /> 21 <br /> ---�d�_ CD <br /> Subdivision..... $25.00 + $2.00 per lot. <br /> Land Use................................. $10.00 <br /> z; <br /> Building..................................cl-OUD <br /> Sanitary .......... H.00 <br /> Well ........................................ 10.00 <br /> Septic Tank ............................ 10.00 <br /> Privy ....................................... 5.00 <br /> v <br /> :.:................. . .... . ..: ..... . . 7.l .... <br /> Signature of Owner or gent to Zoni g ministrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <br /> ................................................................................................................................................................................................ <br /> ................................................................................................................................................................................................ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />